Health Care Statistics
World Health Statistics
Country Profile
Development of health insurance in Mali in recent years has largely centered around Mutuelles. In other words, health insurance is largely voluntary and organized at the community level. The law that governs Mutuelles in Mali is written as follows: “Mutuelles are non-profit groups. Largely using dues from their members, they work in the interest of the members and their families to provide care, solidarity and mutual assistance.” This stems from two major geographic and demographic factors: the geographic dispersion of Mali’s population, and the high level of informal and agricultural sector employment.
Development of health insurance in Mali in recent years has largely centered around Mutuelles. In other words, health insurance is largely voluntary and organized at the community level. The law that governs Mutuelles in Mali is written as follows: “Mutuelles are non-profit groups. Largely using dues from their members, they work in the interest of the members and their families to provide care, solidarity and mutual assistance.” This stems from two major geographic and demographic factors: the geographic dispersion of Mali’s population, and the high level of informal and agricultural sector employment.
Mali’s low population density masks the contrast between the sparsely populated northern part of the country with 360,000 inhabitants over an area of 690,000 km2, and the southern part, in which 8.6 million people are concentrated over 550,000 km2. In this zone, 5.2 million inhabitants live in the space occupied by the Sikasso-Bamako-Mopti triangle, an area of 100,000 km2. In other words, 58% of the people live in 8% of the country’s area. Mali is relatively under-urbanized compared to the other countries in the sub-region, with 22% of the population living in cities, versus 36% in Senegal and 45% in Côte d'Ivoire.
Mali’s level of informal sector employment is high. 80% of Mali’s the labor force works in the informal sector in Mali, and there are more women than men in this sector.
There have been three main periods in the development of the Mutuelle system in Mali:
- The colonial period, when corporation Mutuelles were founded. These are groups which, although they were founded on the principle of solidarity, were more specific to unions or a management body in the company in which they were created. At the time, health was not a priority for these Mutuelles. When the country became independent, Mutuelles did not develop largely due to the policies that Mali adopted.
- The second period was in the 1980s, with the effects of the structural adjustment programs that made civil servants in particular aware of the necessity of developing solidarity instruments to protect against shocks encountered. This will was manifested by the creation and development of Mutuelles, including the education workers Mutuelle and the MUTEC culture, which is the prototype. These Mutuelles were more interested in guaranteeing pension and/or death benefits for their members. They used concepts of solidarity and welfare for certain risks such as retirement and did so due to the difficulties in accessing pensions.
- The third era in the development of the Mutuelle system in Mali began in the 1990s with the adoption of the sectoral health policy and especially the Ten-Year Health and Social Development Plan. In each of the two programs of this plan, there was one component dedicated to the development of alternative financing systems for health through Mutuelles. A legal framework was also identified with the adoption in 1996 of the law that governs the Mutuelle systems in the Republic of Mali and four implementing regulations for this law, consisting of two decrees and two orders, one of which was an interministerial order.
In Mali, the health situation continues to be characterized by a persistently high mortality and morbidity rate, especially among mothers and children. Infectious and parasitic diseases, nutritional deficiencies in children and pregnant women, and insufficient hygiene and health education are the determinants that are the basis for the poor health of the people. Malaria continues to be a public health issue due to its impact on pregnant women and children under five in particular, and is the leading cause of consultations at health facilities.
Despite progress in improving geographical accessibility (at the end of 2008, 80% of Malians lived less than 15 km from a health center), the use of health services is still low, at 0.29 new contacts per inhabitant per year. This situation is due to low household incomes and financial inaccessibility, as well as other factors.
Mali
Historical Context
Development of health insurance in Mali in recent years has largely centered around Mutuelles. In other words, health insurance is largely voluntary and organized at the community level. The law that governs Mutuelles in Mali is written as follows: “Mutuelles are non-profit groups. Largely using dues from their members, they work in the interest of the members and their families to provide care, solidarity and mutual assistance.” This stems from two major geographic and demographic factors: the geographic dispersion of Mali’s population, and the high level of informal and agricultural sector employment.
Mali’s low population density masks the contrast between the sparsely populated northern part of the country with 360,000 inhabitants over an area of 690,000 km2, and the southern part, in which 8.6 million people are concentrated over 550,000 km2. In this zone, 5.2 million inhabitants live in the space occupied by the Sikasso-Bamako-Mopti triangle, an area of 100,000 km2. In other words, 58% of the people live in 8% of the country’s area. Mali is relatively under-urbanized compared to the other countries in the sub-region, with 22% of the population living in cities, versus 36% in Senegal and 45% in Côte d'Ivoire.
Mali’s level of informal sector employment is high. 80% of Mali’s the labor force works in the informal sector in Mali, and there are more women than men in this sector.
There have been three main periods in the development of the Mutuelle system in Mali:
- The colonial period, when corporation Mutuelles were founded. These are groups which, although they were founded on the principle of solidarity, were more specific to unions or a management body in the company in which they were created. At the time, health was not a priority for these Mutuelles. When the country became independent, Mutuelles did not develop largely due to the policies that Mali adopted.
- The second period was in the 1980s, with the effects of the structural adjustment programs that made civil servants in particular aware of the necessity of developing solidarity instruments to protect against shocks encountered. This will was manifested by the creation and development of Mutuelles, including the education workers Mutuelle and the MUTEC culture, which is the prototype. These Mutuelles were more interested in guaranteeing pension and/or death benefits for their members. They used concepts of solidarity and welfare for certain risks such as retirement and did so due to the difficulties in accessing pensions.
- The third era in the development of the Mutuelle system in Mali began in the 1990s with the adoption of the sectoral health policy and especially the Ten-Year Health and Social Development Plan. In each of the two programs of this plan, there was one component dedicated to the development of alternative financing systems for health through Mutuelles. A legal framework was also identified with the adoption in 1996 of the law that governs the Mutuelle systems in the Republic of Mali and four implementing regulations for this law, consisting of two decrees and two orders, one of which was an interministerial order.
In Mali, the health situation continues to be characterized by a persistently high mortality and morbidity rate, especially among mothers and children. Infectious and parasitic diseases, nutritional deficiencies in children and pregnant women, and insufficient hygiene and health education are the determinants that are the basis for the poor health of the people. Malaria continues to be a public health issue due to its impact on pregnant women and children under five in particular, and is the leading cause of consultations at health facilities.
Despite progress in improving geographical accessibility (at the end of 2008, 80% of Malians lived less than 15 km from a health center), the use of health services is still low, at 0.29 new contacts per inhabitant per year. This situation is due to low household incomes and financial inaccessibility, as well as other factors.
The institutional reform in 2000 created the National Social Protection and Economic Solidarity Department, providing better supervisory capacity with the creation of a unit dedicated to strengthening stakeholder capacities for developing the Mutuelle system. These include the Association Support Center, Mutuelle and Cooperative Societies (CAMASC). In 2002, the government of Mali adopted a national social protection policy, followed in 2004 by a national action plan to extend social protection for the 2005-2009 period. These documents indicated the contours of the universal health coverage strategy in Mali. In other words, establishing mandatory health insurance for civil servants, workers and members of parliament (MPs), implementing a medical assistance system to ensure that the poor were able to obtain health care, and developing Mutuelles for the informal and agricultural sector.
The institutional reform in 2000 created the National Social Protection and Economic Solidarity Department, providing better supervisory capacity with the creation of a unit dedicated to strengthening stakeholder capacities for developing the Mutuelle system. These include the Association Support Center, Mutuelle and Cooperative Societies (CAMASC). In 2002, the government of Mali adopted a national social protection policy, followed in 2004 by a national action plan to extend social protection for the 2005-2009 period. These documents indicated the contours of the universal health coverage strategy in Mali. In other words, establishing mandatory health insurance for civil servants, workers and members of parliament (MPs), implementing a medical assistance system to ensure that the poor were able to obtain health care, and developing Mutuelles for the informal and agricultural sector.
Despite a strong political commitment from the authorities, expressed in various documents including the Ten-Year Health and Social Development Plan, the Social Protection Policy Declaration, and the Social Protection Extension Plan, the development of Mutuelles continued, however, to be slow in the field in terms of implementation. In 2010, there were 151 registered Mutuelles, divided very unevenly throughout the country. With 44 Mutuelles, the District of Bamako has slightly over one-third of the total, followed by the regions of Sikasso and Ségou, also with more than one-third (combined), while the Kidal region still has no Mutuelles. The 151 Mutuelles had 104,986 members for a total of 375,496 beneficiaries, for a 2.9% coverage rate. Although many Mutuelles in Bamako and the regional capitals are inter-company and thus include different socio-occupational categories, the majority of them are in rural areas and their members are essentially farmers.
In 2009, the legislative provision was adopted that created the contribution system for mandatory health insurance (AMO) and the non-contribution medical assistance system (RAMED). These two systems were supposed to cover just over 22% of the population through a mandatory and formal contribution system, with the vast majority of the people covered by a voluntary health insurance system. The stakeholders in the Mutuelle movement then reached a consensus on the necessity of a major shift in the strategies for developing Mutuelles. A new strategic framework to extend health insurance to the majority of the population employed in the informal and rural sectors was deemed necessary. The Ministry of Social Protection began a process that culminated in writing a national strategy to have the Mutuelles in Mali extend health coverage that was adopted in 2011.
The social protection policy in Mali has one contributory system and two non-contributory systems. Together they will provide universal coverage for the people of Mali. The target population of the three systems is shown in Table 1.
Table 1: Target population of the social protection system in Mali:
| System | Target population | % of targeted population | Population (millions) |
|---|---|---|---|
| Mandatory health insurance | Civil servants, contractors, employees, MPs, retirees and their beneficiaries | 17 | 2.465 |
| RAMED | The indigent and their beneficiaries | 5 | 0.725 |
| Mutuelles | Informal and agricultural sector | 78 | 11.310 |
Source: Ministry of Social Protection
The AMO and RAMED are new systems for which it was necessary to implement a new institutional architecture, described later in the section entitled “Institutional Structure.” Formal sector workers, who are the target of the AMO today, were previously largely affiliated with Mutuelles on a voluntary basis. Today, this population is required to join the AMO.
The indigent that RAMED targets were not covered by insurance in the past, as they were unable to pay the Mutuelle membership dues on their own.
In contrast, the existing Mutuelles in rural areas in Mali are already targeting the informal and agricultural sector, but they cover only a small percentage of the population. The national extension strategy plans for a systematic scale-up with an innovative organization scheme. The existing Mutuelles do not observe the contours of this new organization scheme, and there will be a need for mergers and harmonization as a result. Additionally, other Mutuelles will be created in areas that at this point are not covered.
It should be noted that in terms of effective coverage, this is the initial stage for Mali. The AMO and RAMED are becoming operational in 2011, and the Mutuelle extension strategy, approved in February 2011, includes a three-year pilot phase (2011-2014). The objective in terms of coverage rates will not exceed 40%, for all systems combined, by 2014.
Mali
Summary of Reforms
The institutional reform in 2000 created the National Social Protection and Economic Solidarity Department, providing better supervisory capacity with the creation of a unit dedicated to strengthening stakeholder capacities for developing the Mutuelle system. These include the Association Support Center, Mutuelle and Cooperative Societies (CAMASC). In 2002, the government of Mali adopted a national social protection policy, followed in 2004 by a national action plan to extend social protection for the 2005-2009 period. These documents indicated the contours of the universal health coverage strategy in Mali. In other words, establishing mandatory health insurance for civil servants, workers and members of parliament (MPs), implementing a medical assistance system to ensure that the poor were able to obtain health care, and developing Mutuelles for the informal and agricultural sector.
Despite a strong political commitment from the authorities, expressed in various documents including the Ten-Year Health and Social Development Plan, the Social Protection Policy Declaration, and the Social Protection Extension Plan, the development of Mutuelles continued, however, to be slow in the field in terms of implementation. In 2010, there were 151 registered Mutuelles, divided very unevenly throughout the country. With 44 Mutuelles, the District of Bamako has slightly over one-third of the total, followed by the regions of Sikasso and Ségou, also with more than one-third (combined), while the Kidal region still has no Mutuelles. The 151 Mutuelles had 104,986 members for a total of 375,496 beneficiaries, for a 2.9% coverage rate. Although many Mutuelles in Bamako and the regional capitals are inter-company and thus include different socio-occupational categories, the majority of them are in rural areas and their members are essentially farmers.
In 2009, the legislative provision was adopted that created the contribution system for mandatory health insurance (AMO) and the non-contribution medical assistance system (RAMED). These two systems were supposed to cover just over 22% of the population through a mandatory and formal contribution system, with the vast majority of the people covered by a voluntary health insurance system. The stakeholders in the Mutuelle movement then reached a consensus on the necessity of a major shift in the strategies for developing Mutuelles. A new strategic framework to extend health insurance to the majority of the population employed in the informal and rural sectors was deemed necessary. The Ministry of Social Protection began a process that culminated in writing a national strategy to have the Mutuelles in Mali extend health coverage that was adopted in 2011.
The social protection policy in Mali has one contributory system and two non-contributory systems. Together they will provide universal coverage for the people of Mali. The target population of the three systems is shown in Table 1.
Table 1: Target population of the social protection system in Mali:
| System | Target population | % of targeted population | Population (millions) |
|---|---|---|---|
| Mandatory health insurance | Civil servants, contractors, employees, MPs, retirees and their beneficiaries | 17 | 2.465 |
| RAMED | The indigent and their beneficiaries | 5 | 0.725 |
| Mutuelles | Informal and agricultural sector | 78 | 11.310 |
Source: Ministry of Social Protection
The AMO and RAMED are new systems for which it was necessary to implement a new institutional architecture, described later in the section entitled “Institutional Structure.” Formal sector workers, who are the target of the AMO today, were previously largely affiliated with Mutuelles on a voluntary basis. Today, this population is required to join the AMO.
The indigent that RAMED targets were not covered by insurance in the past, as they were unable to pay the Mutuelle membership dues on their own.
In contrast, the existing Mutuelles in rural areas in Mali are already targeting the informal and agricultural sector, but they cover only a small percentage of the population. The national extension strategy plans for a systematic scale-up with an innovative organization scheme. The existing Mutuelles do not observe the contours of this new organization scheme, and there will be a need for mergers and harmonization as a result. Additionally, other Mutuelles will be created in areas that at this point are not covered.
It should be noted that in terms of effective coverage, this is the initial stage for Mali. The AMO and RAMED are becoming operational in 2011, and the Mutuelle extension strategy, approved in February 2011, includes a three-year pilot phase (2011-2014). The objective in terms of coverage rates will not exceed 40%, for all systems combined, by 2014.
The near simultaneous implementation of three health coverage systems in Mali is a major challenge. New agencies and systems are in the process of acquiring the necessary skills to carry out tasks such as collecting and managing resources, purchasing services, rulemaking, and process monitoring and evaluation.
The near simultaneous implementation of three health coverage systems in Mali is a major challenge. New agencies and systems are in the process of acquiring the necessary skills to carry out tasks such as collecting and managing resources, purchasing services, rulemaking, and process monitoring and evaluation.
For the Mutuelle system, the tasks will be tested as part of a pilot phase that generates prerequisites in terms of organizing the Mutuelles at different administrative levels, identifying a financing system to collect the contribution from the government, dues from the beneficiaries, and others from various sources that are intended to support the process. For RAMED and the AMO, no pilot phase is planned.
Mali
The Way Forward
The near simultaneous implementation of three health coverage systems in Mali is a major challenge. New agencies and systems are in the process of acquiring the necessary skills to carry out tasks such as collecting and managing resources, purchasing services, rulemaking, and process monitoring and evaluation.
For the Mutuelle system, the tasks will be tested as part of a pilot phase that generates prerequisites in terms of organizing the Mutuelles at different administrative levels, identifying a financing system to collect the contribution from the government, dues from the beneficiaries, and others from various sources that are intended to support the process. For RAMED and the AMO, no pilot phase is planned.